Intercollegiate general surgery guidance on COVID-19

COVID-19 - The updates cautions healthcare professionals to follow guidelines and also apply common sense to at risk clinical environments

The four Royal Surgical Colleges (The Royal College of Surgeons of Edinburgh, Royal College of Surgeons of England, Royal College of Physicians and Surgeons of Glasgow and the Royal College of Surgeons in Ireland), the Association of Surgeons of Great Britain & Ireland, the Association of Coloproctology of Great Britain & Ireland and the Association of Upper Gastrointestinal Surgeons have issued guidance for surgeons regarding procedures during the COVID-19 outbreak. The guidance has also been sent to NHS England and NHS Scotland.

Surgeons will continue to care for patients in the current crisis, especially emergencies. Patient care will be affected if surgeons become sick and leave work. The guidance updates recent guidance as further information has now emerged from government, Italy and China. The updates cautions healthcare professionals to follow guidelines and also apply common sense to at risk clinical environments. Consider COVID-19 infection possible in every patient. While priorities may change as rapid testing becomes available, these are our combined updated guidelines:

Acute patients are the priority. COVID-19 should be sought in any patient needing emergency surgery by history, COVID-19 testing, recent CT chest (last 24h) or failing that CXR. Any patient undergoing abdominal CT scan must also have CT chest.

Any patient currently prioritised to undergo urgent planned surgery must be assessed for COVID-19 as above and the current greater risks of adverse outcomes factored into planning and consent. Consider stoma formation rather than anastomosis to reduce need for unplanned post-operative critical care for complications.

Full Personal Protective Equipment (PPE) should be used for laparotomy except perhaps when the patient is convincingly negative for COVID-19, but note that current tests maybe false negative. Full PPE includes wearing visors or eye protection. It is imperative to practise donning and doffing PPE in advance.

Laparoscopy should generally not be used as it risks aerosol formation and infection. Chinese and Italian experience reflects this. SAGES have offered guidance. Advocated safety mechanisms (filters, traps, careful deflating) are difficult to implement. Consider laparoscopy only in extremely selected cases where the mortality benefit is substantially beyond doubt in the current situation.

Use appropriate non-operative treatment of appendicitis or open appendicectomy.

Treat acute biliary disease conservatively for now or with cholecystostomy.

In theatre:

Minimum number of staff in theatre

Full protective PPE including visors for all staff in theatre

Stop positive ventilation in theatre during procedure and for at least 20 minutes after the patient has left theatre

Smoke evacuation for diathermy / other energy sources

Patients are intubated and extubated in theatre – staff immediately present should be at a minimum.

Risk situations in surgery also include:

Approaching a coughing patient, for example, even if COVID-19 has not been diagnosed. Protection including eye shield is needed.

Naso-gastric tube placement is an aerosol generating procedure (AGP). AGPSs are high risk. Full PPE is needed. Consider carrying out in a specified location.

Only emergency endoscopic procedures should be performed . No diagnostic work to be done and BSG guidance followed. Upper GI procedures are high risk AGPs and full PPE must be used.

“These guidelines are designed to protect our members and fellows but also to protect patients,” Professor S Michael Griffin, President RCSEd. “As a group we are doing everything we can to protect our fellow Surgeons working at the front line of this outbreak and their patients.”